Basic Information
| Provider Information | |||||||||
| NPI: | 1922024074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 N HIGH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432012460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142996600 | ||||||||
| FaxNumber: | 6144213111 | ||||||||
| Practice Location | |||||||||
| Address1: | 6435 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432131507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148569610 | ||||||||
| FaxNumber: | 6148615411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 12/19/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | I0005568 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | I.0005568 | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0274411 | 05 | OH | MEDICAID |